The influenza pandemic of 1918-1919 killed more people
than the Great War, known today as World War I (WWI), at somewhere between
20 and
40 million people. It has been cited as the most devastating epidemic in
recorded world history. More people
died of influenza in a single year than in four-years of the Black Death
Bubonic Plague from 1347 to 1351. Known as "Spanish Flu" or "La
Grippe" the influenza of 1918-1919 was a global disaster.

The Grim Reaper by Louis Raemaekers

In the fall of 1918 the Great War in Europe was winding down and peace
was on the horizon. The Americans had joined in the fight, bringing the
Allies closer to victory against the Germans. Deep within
the trenches these men lived through some of the most brutal conditions of
life, which it seemed could not be any worse. Then, in pockets across the
globe, something erupted that seemed as benign as the common cold. The
influenza
of that season, however, was far more than a cold. In the two years
that this scourge ravaged the earth, a fifth of the world's population
was infected. The flu was most deadly for people ages 20 to 40. This
pattern of morbidity was unusual for influenza which is
usually a killer of the elderly and young children. It infected 28% of
all Americans (Tice). An estimated 675,000 Americans died of influenza
during the pandemic, ten
times as many as in the world war. Of the U.S. soldiers who died in
Europe, half of them fell to the influenza virus and not to the enemy
(Deseret News). An estimated 43,000 servicemen mobilized for WWI died of
influenza (Crosby). 1918 would go down as unforgettable year of suffering
and death and yet of peace. As noted in the Journal of the American
Medical Association final edition of 1918:

"The 1918 has gone: a year momentous as the
termination of the
most cruel war in the annals of the human race; a year which marked, the
end at least for a time, of man's destruction of man; unfortunately a year
in which developed a most fatal infectious disease causing the death of
hundreds of thousands of human beings. Medical science for four and
one-half years devoted itself to putting men on the firing line and
keeping them there. Now it must turn with its whole might to combating
the greatest enemy of all--infectious disease,"

(12/28/1918).

An Emergency Hospital for Influenza Patients

The effect of the influenza epidemic was so severe
that the average life span in the US was depressed by 10 years.
The influenza virus had a profound virulence, with a mortality rate at
2.5% compared to the previous influenza epidemics, which were less than
0.1%. The death rate for 15 to 34-year-olds of influenza and pneumonia
were 20 times higher in 1918 than in previous years (Taubenberger).
People were struck with illness on the street and died rapid deaths. One
anectode shared of 1918 was of four women playing bridge together late
into the night. Overnight, three of the women died from
influenza (Hoagg). Others told stories of people on their way to work
suddenly developing the flu and dying within hours (Henig). One physician
writes that patients with seemingly ordinary influenza would rapidly
"develop the most viscous type of pneumonia that has ever been seen" and
later when cyanosis appeared in the patients, "it is simply a struggle for
air until they suffocate,"
(Grist, 1979). Another physician recalls that the influenza patients "died
struggling to clear their airways of a blood-tinged froth that sometimes
gushed from their nose and mouth," (Starr, 1976). The physicians of the
time were helpless against this powerful agent of influenza. In 1918
children would
skip rope to the rhyme (Crawford):

I had a little bird,

Its name was Enza.

I opened the window,

And in-flu-enza.

The influenza pandemic circled the globe. Most of humanity
felt the effects of this strain of the influenza virus. It spread
following the path of its human carriers, along trade routes and shipping
lines. Outbreaks swept through North America, Europe, Asia, Africa,
Brazil and the South Pacific (Taubenberger). In India the mortality rate
was extremely high at around 50 deaths from influenza per 1,000 people
(Brown).
The Great War, with its mass movements of men in armies and
aboard ships, probably aided in its rapid diffusion and attack. The
origins of the deadly flu disease were unknown but widely
speculated upon. Some of the allies thought of the epidemic as a
biological warfare tool of the Germans. Many thought it was
a result of the trench warfare, the use of mustard gases and the generated
"smoke and fumes" of the war. A national campaign began using the ready
rhetoric of war to fight the new enemy of microscopic proportions.
A study attempted to reason why the disease had been so devastating in
certain localized regions, looking at the climate, the weather and the
racial composition of cities. They found humidity to be linked with more
severe epidemics as it "fosters the dissemination of the bacteria,"
(Committee on Atmosphere and Man, 1923). Meanwhile the new sciences of the infectious agents and
immunology were racing to come up with a vaccine or therapy to stop the
epidemics.

The experiences of people in military camps encountering the influenza
pandemic:

An excerpt for the memoirs of a survivor at Camp Funston of the
pandemic
Survivor

A letter to a fellow physician describing conditions during the
influenza epidemic at
Camp Devens

A collection of letters of a soldier stationed in Camp Funston Soldier

The origins of this influenza variant is not precisely known. It is
thought to have originated in China in a rare genetic shift of the
influenza virus. The recombination of its surface proteins created a virus
novel to almost everyone and a loss of herd immunity. Recently the virus
has been reconstructed from the tissue of a dead soldier and is now being
genetically
characterized. The name of Spanish Flu came from the early affliction
and large mortalities in Spain (BMJ,10/19/1918) where it allegedly killed 8 million in May (BMJ, 7/13/1918).
However, a first wave of influenza appeared early in the spring of 1918 in
Kansas and in military camps throughout the US. Few noticed the epidemic
in the midst of the war. Wilson had just given his 14 point address. There
was virtually no response or acknowledgment to the epidemics in March and
April in the military camps. It was unfortunate that no steps were taken
to prepare for the usual recrudescence of the virulent influenza strain in the winter. The lack of action was
later criticized when the epidemic could not be ignored in the winter of
1918 (BMJ, 1918). These first epidemics at training camps were a sign of
what was coming in greater magnitude in the fall and winter of 1918 to the
entire world.

The war brought the virus back into the US for the second wave of the
epidemic. It first arrived in Boston in September of 1918 through the port
busy with war shipments of machinery and supplies. The war also enabled
the virus to spread and diffuse. Men across the nation were mobilizing to
join the military and the cause. As they came together, they brought the
virus with them and to those they contacted. The virus killed almost
200,00 in October of 1918 alone. In November 11 of 1918 the end of the
war enabled a resurgence. As people celebrated Armistice Day with parades
and large partiess, a complete disaster from the public health standpoint, a rebirth
of the epidemic occurred in some cities. The flu that winter was beyond
imagination as
millions were infected and thousands died. Just as the war had effected
the course of influenza, influenza affected the war. Entire fleets were
ill with the disease and men on the front were too sick to fight. The
flu was devastating to both sides, killing more men than their own
weapons could.

With the military patients coming home from the war with battle
wounds and mustard gas burns, hospital facilities and staff were taxed to
the limit. This created a shortage of physicians, especially in the
civilian sector as many had been lost for service with the military.
Since the medical practitioners were away with the troops, only the
medical students were left to care for the sick. Third and forth year
classes were closed and the students assigned jobs as interns or nurses
(Starr,1976). One
article noted that "depletion has been carried to such an extent that the
practitioners are brought very near the breaking point," (BMJ, 11/2/1918).
The shortage was further confounded by the added loss of physicians to the
epidemic. In the U.S., the Red Cross had to recruit more
volunteers to contribute to the new cause at home of fighting the
influenza epidemic. To respond with the fullest utilization of nurses,
volunteers and medical supplies, the Red Cross created a National
Committee on Influenza. It was involved in both military and
civilian sectors to mobilize all forces to fight Spanish influenza
(Crosby, 1989). In some areas of the US, the nursing shortage was so
acute that the Red Cross had to ask local businesses to allow workers to
have the day off if they volunteer in the hospitals at night (Deseret
News). Emergency hospitals were created to take in the patients from the
US and those arriving sick from overseas.

The pandemic affected everyone. With one-quarter of the US and
one-fifth of the world infected with the influenza, it was impossible to
escape from the illness. Even President Woodrow Wilson suffered from the
flu in early 1919 while negotiating the crucial treaty of Versailles to
end the World War (Tice). Those who were lucky enough to avoid infection
had to deal with the public health ordinances to restrain the spread of
the disease. The public health departments distributed gauze masks to be worn in public. Stores
could not hold sales, funerals were limited to 15 minutes. Some towns
required a signed certificate to enter and railroads would not accept
passengers without them. Those who ignored the flu ordinances had to pay
steep fines enforced by extra officers (Deseret News). Bodies
pilled up as the massive deaths of the epidemic ensued. Besides the lack
of health care workers and medical supplies, there was a shortage of
coffins, morticians and gravediggers (Knox). The conditions in 1918 were
not so far removed from the Black Death in the era of the bubonic
plague of the Middle Ages.

In 1918-19 this deadly influenza pandemic erupted during
the final stages of World War I. Nations were already attempting to
deal with the effects and costs of the war. Propaganda campaigns and war
restrictions and rations had been implemented by governments. Nationalism
pervaded as people accepted government authority. This allowed the
public health departments to easily step in and implement their
restrictive measures. The war also gave science greater importance as
governments relied on scientists, now armed with the new germ theory and
the development of antiseptic surgery, to design vaccines and reduce
mortalities of disease and battle wounds. Their new technologies could
preserve the men on the front and ultimately save the world. These
conditions created by World War I, together
with the current social attitudes and ideas, led to the relatively calm
response of the public and application of scientific ideas. People
allowed for strict measures and loss of freedom during the war as they
submitted to
the needs of the nation ahead of their personal needs. They had accepted
the limitations placed with rationing and drafting. The
responses of the public health officials
reflected the new allegiance to science and the wartime society. The
medical and scientific communities had developed new theories and applied
them to prevention, diagnostics and treatment of the influenza patients.